28585 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE HALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28585
BIIIIAING PROJECT IT)EN'HFICATION
BUyyIILrL INGADDRESS: SANITARY NO. APPLICATION SUBMI ALDA'rE
OW 'SN E: PHO E: CONE R'SNA LI NO: • � �/
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tls,ill'PL'Cf/ENGINCL'R: CNO: ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ .T ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby aim that 1 see licermrd under provisions of Chapter 9(commencing JOB DESCRIPTION
Qat with Section 7000)of DivisionJofNe Businesses Professions Cod andm license is
QO 1jy/� y PERMIT ISSUANCE RESIDENTIAL:
I full forte anJ s 7
�' ❑SFDWL ❑KITCHEN REMODEL
�U LiceneeC s Contractor
1 APPLIANCES-RESIDENTIAL
� Date � Conuanmr ❑ADDITION [D PLUMBING RE-PIPE
f� RCHDECT'S DECLARATION PANELS 0MULTI.UNIT .. ❑STRUCTURAL
Z O r1 mdcodm d my plans shall be dsed as public res o da s MODIFICATION
0z�t UPTO 200 AMPS
F� O ❑INTERIOR El CHIMNEY REPAIR
{y Licensed Pmfessiotul 301-IOOOAMPS IMPROVEMENT
pd -aJ OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
PPaCC U I I hereby affirm on I on exempt from the Contractor's License Law far the
following aresmason,(Section 7071.5,Businessandmpr ere.d arsol Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W which requires a period rc construct,epee improve.demolish,or repair any structure /�
�m priormits iswanc<.dw rtquirea the applicant( such peon" file a signal ntmemem SPECIAL CIRCUIT/MISC.
<� that he is licensed Parsuanno the Ems ansufth Contranora License Law(Chapter9 COMMERCIAL
CCQO (commencing with Secrion]IXKpo Rosiness and Prof ssiam Code)or TEMP.METER OR POLE DIST.
that he is exempt therefrom anti th ass u al used exenril Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section]031.5byenyapplicu for objects the ap noca
ivil penahyof POWER DEVICES [I TENANT ❑FOOD SERVICE
not more than ere hand ds I
O ❑Laidne r ppe my emwdasWa¢es to compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
a will do the mreis notimen eJo f _}form ( ec.]044,Business []OTHER
L and Protestant a The n to5b Li La does no,apply ro an owner of OUTLETS-SWITCHES-FUTURES
.. property who hot s mpro es rfon who
does such work himself or through
his own employe , ro"did such improvements are not intended or offered fur NEW RESIDF.NT'IAL ELECTR SQ PT.
WeAf,hawever,th uiId,iso improvement is sold within one year ofcompleduar.the SQ.FT FLOOR AREA $/SQ.Pi
owrmr-builder will have the burden estimating that he did not build or improve for pur-
poseof sde.).
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.70,14,Business and Professions Ccsi The Contractors LI.
came Law does act apply to an owner of property who builds or nuances themon,and CITY.. PLUMBING PERMIT FEE
who contracts for such Fmjwts with a comremuns)licensed pursuant the Contractors
License Law. PERMIT ISSUANCE
Iem exam t nderStt ,B A P C for this sawn
Dat ALTER-DRAINA VENT-WATER(EA) VALUATIf�(s'JL
ORKEI'S COMPENS ION DECLARATION BACK FLOW PROTECT.DEVICE
.I hereb affirm under Penalty ofperjury one oftbe following declarations: d
❑lhave and will maimne a Cmificate ofComenuo self-insure for Workers Coalition- DRAINS-FLOOR,ROOF,AREA,COND. RIES TYPE CONSTRUCTION
sation,as provided for by Section 3]00 of the Labor Code,for Ne performm¢e of the
work for which this Permit in issued. FIXTURES-PER TRAP
❑ I me.11 will naimain Worker's Compensation Insurance,as required by Section
3]W of the Lob afor the performance of for which this Permit is iswed. GAS-EA,SYSTEM.I INC.4 OUTLETS - OCC,GROUP APN
My Worker's mia are a i y ntpmher arc.
Carrier. GAS-EA.SYSTEM-OVER 4(EAI
CERT : ATEOFE%EMPTION FROM WORKERS'
COMPENSATION INSURANCEGREASPANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not he completed if the Permit is for one hundred dollars($100) GRF.ASHTRAP
or lereJ - PLANCHECK FEE
I ccnify that in the perfmmnnce of the work fnrwhich this permit is issued,i shall SEWER-SANITARY-STORM EA.3011 FT.
not employ any peri many mammy was tee become subject to Ne Workers'Camper. ENERGY FEE
Z sedan laws of Com mit.Dam
O O Applicant WATER HEATER WNENT/ELF.CfR GRADING FEE
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSI Plain BEATING
f'! become subject o the Workers Cooperation provisions of the Labor Cade,you must SOILS FEE
{iW7 foMwint comply wish such provisions or Nie permit shall be thermal revoked. WATER SERVICE
0
UO CONSI UCTIONLENDING AGENCY NEW RESIO[:KTIALPLMB. SQ.FT. PAID
I herebyaffirmthis
that them isaed(Sectian lending agency for the performance of Date Rtteiptp
the work for which this permit is issued(Sec.3W],Civ.CJ
O U Lenders Name TOTAL:
Lenders Address TOTAL:
a 1 comfy that I have read this application and state that the above information is - BUILDING FEE
V2 correct.I agree to comply with all city and county ordinances end nate laws relating to QTY. MECHANICAL PERMIT FEE
U boildingconstmction,and hereby authorise mineummivesof Nis city mmnerugm the SEISMIC FEE
above-mentiened property far inspection purpmm. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino eg.imt ELECTRIC FEE
liabilities,jol,res a,count and cinch.which may in any way ocente against said City ALTER OR ADD TO MECH.
n consequence of Ne granting of this permit. PLUMBING ME
APPLICANT UNDE STAN 5 AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0130 CFM)
SOURC UL ON ///1 MECHANICAL FEE
/7AIR HANDLING UNIT(OVER 10,000 CFNE CONSTRUCTION TA& p ,^
S ren ican mursi T //Date EXHAUST HOLD(W/DUCT) _ •-+
HOUSING MITIGATION
HAZARDOUS MATERIALS DISCLOSURE FEE s
Will the applicant or future building accepts score or handle hamrdaus material HEATING UNIT(TO 100,000 BTU)
as coMcd by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety 1001,
Code,Section 15532(0)] HEATING UNIT(OVER 100.000111 U)
[D Yet 0N VENTILATION PAN(SINGLE RESID) PAID_ s
Will the applicant or future building occupant use equipment or devices which l Use UY L-R-iPl .I Ili
'rardnua air conlaminame az defined by the Bay Area Air Qudity Manegemcm BOILER-COMP OHP OR 100,0110 BTU) - r
TOTAL:
❑Yu 71 No BOILER-COMP(OVER 1031 BTU)
I have mad Ne hmsrmus mamids m4drements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCED
formj�luq
Safe Cade,Semi 25505.8533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
buildt oily have CNet it is my responsibilitymnoafy theacupmm
of which mm met Erin to f c ificme of cu cy.
Owncrmam mi te TOTAL:
SSUEDB .
0FFICE